Pre-flight redundancy

[Justin DBC]

Thought I would share this with you guys. Another "complacency kills" scenerio.

 

I was at work the other night getting ready for a NVG progression flight. We were about ready to crank the engines when I realized the aircraft next to us that was about ready to take off was shutting down. About a minute later, I saw a fire truck speeding onto the flight line. It was pretty dark, but I could see a bunch of fluid on the ground underneath the aircraft. We held off on starting the engines so the firefighters could get all the mess soaked up.

 

While we were waiting, assuming that they had a fuel leak, one of the pilots from the other aircraft came over with a camera and showed us a picture. In the oil servicing port on the number one engine was, I sh*t you not, a can of oil.

 

The pilots on this crew were 2 of the most experienced guys we have. The crew chief is also another one of our most experienced guys. None of them have dicipline issues and they are all typically very safety concious.

 

I'm not sure exactly how this slipped by, but there is obviously no good reason. There were 3 crew members and at least 2 of them should have done a thorough pre-flight. I have been quite guilty myself of taking the pilot's word that the pre-flight was good and just going through and spot checking a few of the more important things. Important reminder for that crew, myself, and hopefuly at least one other person on this board.

 

J-

[apiaguy]

so why the fire truck? Pilot couldn't get out and see what was on the ground? Maybe not his job in the NG.

[CharyouTree]

What was missed on pre-flight? Can you show me in the -10 where it requires you to open the engine cowling for pre-flight?

 

I only say this because while overseas my company commander did a flight, and at some point afterward; post-flight, or daily, it was discovered that the oil cap wasn't in place. I made the mistake of asking how he missed it on pre-flight (this was prior to flight school for myself).

 

That said, this happens to be one of my "personal checks". (inside the cowling for FOD, and the oil cap in particular.) If the cowling *was* opened, I can't see any good reason why an oil can wouldn't have been noticed.

 

I'm also often the only person to do a preflight on the aircraft I'm flying. When it IS two people, we don't do the same checks. I also do it like I'm buying the thing, but...

Edited March 5, 2009 by CharyouTree

[copter doctor]

Fire Dept. is usally responsable for Hazmat clean up of spills on flight line if it looks big, especially if they thought it was fuel at first.

[Wally]

What is the cliche? You have already screwed up, or you will, and the two aren't exclusive. All you can do is know that it's not only possible, it will happen. All you can do is make the mistake you're going to make as small as possible.

I've missed stuff on preflights. I'm fairly anal about preflights- one base's maintenance manager called my preflights 'daily annuals'- and I've missed stuff. Mostly, when I was distracted or rushed, but it has happened. Plural, I've been at this a long time, and missed more than I care to admit. So far, nothing that's killed me, and I work at keeping them small so when it happens again, it'll be minimal issues...

 

When I was two-pilot crew, I'd work with guys who wanted to 'split' the aircraft. Even if I knew them well enough to trust their preflight, that's an opportunity to miss something and a built-in distraction. I check everything myself.

The only things I don't check are the ones I can't check. I carry an inspection mirror and flashlight for some of those.

I preflight the same way, every time. Methodical is good, especially if interrupted and uncertain of something- I go back to a point earlier and work through the sequence again.

Methodical repetition has a definite drawback, you see what you expect to see. You have to find a way of concentrating that keeps you intellectually aware of what you're checking. Even then, there are times when I can't remember specifically what I've looked at, because it is as it has been as it was, serviceable and unremarkable, nothing memorable. If I'm not certain of that, I check it again.

I used to have a collection of odd tools I'd found on aircraft. I always mention that to the mechanic(s) I work with, they make the same kind of mistakes, and if they owned up to the tool they got it back. No implication, I have great respect for technical capability.

 

I've missed stuff on preflight, and you will too. If you want to live with it, accept that fact, and work to make SMALL mistakes.

[Justin DBC]

What was missed on pre-flight? Can you show me in the -10 where it requires you to open the engine cowling for pre-flight?

 

I only say this because while overseas my company commander did a flight, and at some point afterward; post-flight, or daily, it was discovered that the oil cap wasn't in place. I made the mistake of asking how he missed it on pre-flight (this was prior to flight school for myself).

 

That said, this happens to be one of my "personal checks". (inside the cowling for FOD, and the oil cap in particular.) If the cowling *was* opened, I can't see any good reason why an oil can wouldn't have been noticed.

 

I'm also often the only person to do a preflight on the aircraft I'm flying. When it IS two people, we don't do the same checks. I also do it like I'm buying the thing, but...

 

You are correct. The only thing that you are required to check on the engines is the oil level which you are able to check without opening the engine cowling. Obviously, that is not the best practice to use when it only takes about anothe minute to pop them open when you're checking the APU. I've noticed that most of the shortcuts I've learned are generally bad ieas.

 

Typically, crewchiefs are always supposed to do at least a walk-around checking fuel and oil levels. It's not written anywhere, but the extra set of eyes always helps out. After talking with some people about the incident afterwards, I decided that it's not going to kill me to come in 30 minutes early and do a full pre-flight for myself. At the very least it will be a good example for others to follow and it could prevent something a lot more serious than 7 quarts of oil on the ground.

 

J-

 

 

Fire Dept. is usally responsable for Hazmat clean up of spills on flight line if it looks big, especially if they thought it was fuel at first.

 

Bingo. They do all the Hazmat, so even for the amount of oil that was spilled, it's still their responsibility.

[Mikemv]

To all, a few years ago I was on the ramp in West Palm Beach, Fl. waiting in my B407. My pax had called and said they were on the way, so I was sitting in the aircraft when an EC135 gets pulled out on a dolly and is placed next to me. A pilot comes out and does a quick look at things, then goes back inside briefly. Next, another pilot comes out and gets into the cockpit and then out again. Next they both are there and put on PFD,s so I figure they are going to the Bahamas or at least off shore for some photo work? They run the aircraft up and then after about 2 minutes they shut it down. Then the fuel truck pulls up and gives them some Jet fuel!!!!! We are all human but experience tells me more mistakes happen when 2 people are involved. We should all be most diligent and not let things distract us. The "Sterile Cockpit" theme starts long before we get to the aircraft and finishes long after we leave it. Best to all, Fly Safe, Mike

[Hovergirl]

I agree with Mikemv that two pilots can be more hazardous than one -- not only can they distract each other, but it's really easy to assume that the other guy has taken care of x, while he assumes that you did it. And of course you don't want to be the nervous dweeb that makes the flight take off late, right? If you were working alone you would probably be much less relaxed and double check everything.

[Justin DBC]

Well said Hovergirl. Communication and maintaining a positive work environment are key to avoiding these kinds of mishaps. If you have two people checking the aircraft it never hurts to verbally go through checklist to ensure that nothing was missed. It only takes a minute and saves a lot more time than rushing through and realizing you need to shut down because you skipped a vital step on your pre-flight. It's much better to have at least 2 crewmembers check everything for themselves, but at least if there is a verbal double-check on everything afterwards, you'll know that at least someone had eyes on every item (given your co-workers don't have integrity issues).

 

J-